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Anticipating and Preventing ADEs:
Decreasing the Need to Rescue Hospitalized Patients from Opioid-related
Complications
Session BP5, February 11, 2019
Ashley Meyers, BSN, RN-BC, PCCN-K, Clinical Nurse Educator, Sparrow Hospital
Craig Havican, BSN, RN, Epic ClinDoc Senior Analyst, Sparrow Hospital
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Craig Havican, BSN, RN
Has no real or apparent conflicts of interest to report.
Ashley Meyers, BSN, RN-BC, PCCN-K has the following
relationships to disclose:
Consulting Fees (e.g., advisory boards):serving as subject matter expert for
“Alternatives to Opioids in the ED” through Michigan Health and Hospital
Association (HIIN grant funded)
Fees for Non-CME Services Received Directly from a Commercial Interest or
their Agents (e.g., speakers’ bureau):previously served as an unbranded
onsite nurse expert for Mallinckrodt Pharmaceuticals, have not served in this
role in > 12 months
Conflict of Interest
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Background
Identification of the problem
Evidence-based solutions
Implementation
Results
Agenda
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Identify the key elements required to develop a robust MOSS
(Michigan Opioid Safety Score) which includes health risk
assessment, respiratory rate, and other clinical assessments
Outline how to design an IT-enabled nursing workflow using
standard processes for nursing documentation to capture the data
elements required to generate a MOSS score and populate
clinical decision support and ordering
Analyze how to incorporate unit level reporting tools to drive
MOSS assessment compliance by the nursing staff
Outline how to generate a risk for respiratory depression care plan
for patients with high MOSS scores to help prevent the need for
rescue and promote timely intervention when rescue is necessary
Learning Objectives
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Sparrow Health System
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» Sparrow Hospital
» 10,500 Caregivers
» 733 beds
» 31,645 discharges
» CARF Accredited
» Level 1 Regional Trauma
Center
» Sparrow Carson (61 beds)
» Sparrow Specialty Hospital (30
beds)
» Sparrow Clinton (25 beds)
» Sparrow Ionia (22 beds)
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Local Problem
We are in an opioid public health emergency
Opioid administration in hospitalized patients too often harms
those it is intended to help (ADE)
Inpatient administration of the opioid antagonist naloxone for
overmedication is evidence of overuse or misuse
Our data suggested that we could do better
Timely identification and intervention for patients at risk or with
early evidence of respiratory depression should help
(effectiveness, safety, cost)
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Local Problem
Validated tools exist to decrease the risk of iatrogenic overdose
Assessment of level of sedation
Determination of Michigan Opioid Safety Score (MOSS)
Triggering interventions before naloxone rescue is required
Well- designed, pervasively used EMR tools should help improve
clinical outcomes and decrease costs
No EMR-integrated tools and workflows to improve
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Drivers to Take Action: 2012-2014
Escalating national opioid crisis; Michigan’s ranking (10
th
, 18
th
)
Joint Commission Sentinel Alerts
American Society for Pain Management Nursing Guidelines
MHA Keystone Center Opioid ADE Prevention Initiative
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The Joint Commission, 2012
Jarzyna et al., 2011
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Front-Line Nurses Leading the Way
Sparrow Pain Resource Nurses (SPRNs) began looking at quality
data in 2014
Nearly 1% of patients we were treating with opioids in the hospital
experienced opioid-induced respiratory depression (OIRD)
requiring naloxone rescue
To improve this, we set a hospital goal to decrease the rate of
OIRD requiring naloxone rescue using:
People: Governance, leadership, clinicians, IT
Processes: Policies, workflows, Lean methods, PDCA
Technology: IT (EMR); devices (ETC0
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- capnography)
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Sparrow rate of opioid-
induced respiratory
depression (OIRD) as
measured by percent of
inpatients on opioids
requiring naloxone rescue
administration
2014: 0.72%
2015: 0.73%
and increasing
Sparrow Baseline Data
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Narcotics Accounting for
Naloxone Use
Fentanyl Hydrocodone/APAP
Hydromorphone Morphine
Oxycodone
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2015 Naloxone Rate Trend Before
MOSS Implementation
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MOSS Documentation = 0%
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Project Description and Goal
In acutely ill adult inpatients, does
implementation of a an EMR-integrated risk
assessment tool using accepted nursing
workflows that is aimed at preventing OIRD,
decrease the incidence of OIRD compared to
no risk assessment as measured by naloxone
use?
Goal: To decrease rate of IP naloxone rescue
to ≤0.65%
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Benchmarks
Naloxone Target Rate: 0.65%
Numerator: # of patients received opioid &
naloxone
Denominator: # of patient received opioid (any
route)
Aligned with MHA Keystone Pain Management
Collaborative and HIIN
Khelemsky et al., 2015, Caymich, 2017
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Design and Implementation
The knowledge tools we decided to use
Pasero Opioid-Induced Sedation Scale (POSS)
Michigan Opioid Safety Score (MOSS)
The IT tool we decided to use: Epic, because…
Our key to the Sparrow Way and care transformation
Where clinical care gets done…and documented
Decision support: Risk scores, BPAs, care plans
If this works, we can share it with Epic organizations!
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Soto R, Yaldou B. J Perianesth Nurs. 2015;30:196
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Design and Implementation
Review literature
Identify best practices
People, process,
technology
Gather a guiding coalition
Communicate for buy-in
Decide what
good looks
like
Assessment
documentation
Scales & scores
Nursing care plans
CDS tools, displays
Policy-supported
workflows
Build the
solution in
EMR
Application testing
Integrated testing
MOSS education
FMEA, address findings
Policy implications
Test, Talk,
Teach
Nursing leadership sign-
offs
EMR workflow training
Put into nursing practice
Measure, monitor, adjust
Go-live &
PDCA
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More about MOSS
Combines
Health risk assessment
Respiratory rate
Modified POSS (mPOSS)
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Soto R, Yaldou B. J Perianesth Nurs. 2015;30:196
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A SWOT Analysis to Inform Our
Conversion from Paper to EMR
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Strengths
Supporting Literature
Pain Champions
Clear Assessment
Times Multimodal
Pain Management
Order Sets
Weaknesses
Double Documentation
(Paper & Electronic)
Turnover of RN/Nurse
Leadership
Opportunities
Improve Patient
Safety
Increase RN
autonomy
Decrease RRT
Decrease Narcan
Threats
Competing pilots
Equipment
Engagement
Sisco, Cooper, & Rayburn, 2014
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© 2019 Epic Systems Corporation. Used with
permission.
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Preoccupation with Failure to
Promote Success Every Step of the
Way: FMEA
Method
Audience
Other
Disciplines
Content
Key
Stakeholde
rs
Align with
other
initiatives
Timeline
Plan EMR
Build
Evaluate
Documentatio
n Committee
Across
applications
View for other
disciplines
Go-Live
Support
Timeline
Just in time
education
Educate
Implement
Ongoing PI
Risk Mgmt
reporting
PDCA follow-
up plan
Harpel & Giannini, 2014
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How Health IT Was Used
Use standard processes for nursing
documentation (EMR flowsheets) to
capture data for MOSS value
Health risks: e.g., OSA, other
sedatives, age
Respiratory rate: document
once, use many times
mPOSS sedation assessment
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How Health IT Was Used
Program EMR to use
nursing documentation to
calculate MOSS value
Display the MOSS value
where nurses can see and
interpret it
Provide usable, actionable
CDS to drive best
practices
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MOSS Scoring and Action
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How Health IT Was Used
Nursing Documentation
Display of MOSS Value
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© 2019 Epic Systems Corporation. Used with
permission.
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How Health IT Was Used
Clinical decision support
Alerts & advises to add
care plan or exclusion
Adds and opens care plan
Unit level reports
Department managers
RRT nurses
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© 2019 Epic Systems Corporation. Used with
permission.
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How Health IT Was Used: Care Plans
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© 2019 Epic Systems Corporation. Used with
permission.
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Value Derived: Improved Processes
Adherence to Best Practice
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Training
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Training
1
Policy
Req Doc
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Value Derived: Patient Outcomes
Surpassed ADE Benchmark
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Mean
Naloxone
Rate
Relative
Change in
Naloxone
Rate
# of
Patients
Receiving
Naloxone
Per Year
Mean
Incidence
Per Month
2014 0.72% NA 179 14.9
2015 0.74% 2.6% 174 14.5
2016 0.70% -3.2% 157 13
2017 0.55% -23.6% 113 9.4
2018 0.52% -20% 103 8.6
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Value Derived: Patient Outcomes
Jan-15
Apr-15
Jul-15
Oct-15
Jan-16
Apr-16
Jul-16
Oct-16
Jan-17
Apr-17
Jul-17
Oct-17
Jan-18
Apr-18
Jul-18
Oct-18
Naloxone Rate
Naloxone Rate (%) Trend Before vs. After
Implementing
EMR-Integrated MOSS Tool
Naloxone Rate (%)
Benchmark
Linear (Naloxone Rate
(%))
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Value Derived: Improved Processes &
Outcomes
MOSS Documentation Naloxone Rate
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Value Derived: Cost Avoidance as a Result of
Clinical Improvements
Mean
Naloxone Rate
Raw
Incidence
Per Year
Mean
Incidence
Per Month
Estimated Cost
Avoidance
(Raw Incidence vs.
Baseline Year)
2014 0.72 179 14.9
2015 0.74 174 14.5 $70K - $98K
2016 0.70 157 13 $308K - $431K
2017 0.55 113 9.4 $924K - $1,293K
2018 0.52 103 8.6 $1,064K
1,489K
Overall $2,366K 3,311K
Estimated cost per ADE: Non-ICU = $13,994; ICU = $19,685
Sultana J, Cutroneo P, Trifirò G. J Pharmacol Pharmacother. 2013; 4:S73-7.
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Fewer Patients Harmed:
170
Cost Avoidance:
$2.3M - $3.3M
Totals: 2015 2018 YTD
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External Recognition for our IT-enabled
Best Practice: Epic Clinical Program
© 2019 Epic Systems Corporation. Used with
permission.
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External Recognition for our IT-enabled
Best Practice: ECRI Institute
MOSS program recognition
Better processes
Naloxone reductions
Greater staff comfort
Criteria-based prescribing
restrictions (fentanyl)
Safer order sets (PCA)
Pushing nonpharmacologic
pain management modalities
(e.g., heat and cold,
aromatherapy, pet therapy)
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Capital expenses = $ 0
Operational expenses = $57,375
Capital and Operational Expenses
Activity
Cost
PI/Project Planning; 120 total hours
Committee work; 20 total hours
Live and online Nursing Education; 1.5 hours each
Go
-Live Support; 40 total hours
EMR analyst time; 60 total hours
TOTAL
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Involve your frontline staff at the beginning
Sense of ownership of the problem and solution
Partner with IT team at the beginning of implementation planning
One time education & training isn’t enough
Technology and training does not ensure sustainability
Clear expectations and accountability
Lessons Learned
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Ashley Meyers, BSN, RN-BC, PCCN-K Ashley.Meyers@sparrow.org
Craig Havican, BSN, RN Craig.Havican@sparrow.org
Questions
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References
Harpel, J., & Giannini, R. C., (2014). FMEA introduction [PowerPoint Slides]. Retrieved from
http://community.mha.org/HigherLogic/System/DownloadDocumentFile.ashx?DocumentFileKey=12b34156-f4e1-46bd-
9b1d-e6a7019a76f4
Pasero, C., & McCaffery, M. (2010). Pain assessment and pharmacologic management. Elsevier Health Sciences.
Jarzyna, D., Jungquist, C. R., Pasero, C., Willens, J. S., Nisbet, A., Oakes, L. & Polomano, R. C. (2011). American
Society for Pain Management Nursing guidelines on monitoring for opioid-induced sedation and respiratory depression.
Pain Management Nursing, 12(3), 118-145.
Soto, R., & Yaldou, B. (2015). The Michigan Opioid Safety Score (MOSS): A patient safety and nurse empowerment
tool. Journal of PeriAnesthesia Nursing.
Sultana, J., Cutroneo, P., & Trifirò, G. (2013). Clinical and economic burden of adverse drug reactions. Journal of
pharmacology & pharmacotherapeutics, 4(Suppl1), S73.
Sisco, L., Cooper, M., & Rayburn, V. (2014). Strengths, weaknesses, opportunities, threats analysis. Personal
Communication.
The Joint Commission. (2012, August). Sentinel event alert: Safe use of opioids in hospitals. Retrieved from
http://www.jointcommission.org
Yaldou, B., Cooper, M., & Soto, R. (2017). Inter-Rater Reliability and Reception of the Michigan Opioid Safety Score.
Journal of PeriAnesthesia Nursing.